REVIEW REQUEST FOR
Implantable Cardioverter-Defibrillator (ICD)
Provider Data Collection Tool Based on Medical PolicySURG.00033
Policy Last Review Date: 11/18/2010 / Policy Effective Date: 12/01/2010 / Provider Tool Effective Date: 12/01/2010Individual’sName: / Date of Birth:
Insurance Identification Number: / Individual’s Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Facility Name: / Facility ID Number:
Facility Address:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis (ICD-9) if known):
Please check all that apply to the individual:
ADULT INDICATIONS
Request is for implantable cardioverter-defibrillator (ICD) therapy in an adult
Request is for ICD/Biventricular pacing (CRT/ICD) device (*** If checked, you must complete and submit this document as well as the Clinical Data Submission Tool - Cardiac Resyncronizing Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure***)
Request is to treat ventricular tachyarrhythmias and to prevent sudden cardiac death (SCD)
Individual is receiving optimal medical therapy
Individual has a reasonable expectation of survival with a good functional status for more than 1 year
Individual had cardiac arrest due to ventricular fibrillation (VF) or hemodynamically unstable sustained ventricular tachycardia (VT), an evaluation to define the cause of the event has been done, and any completely reversible causes of the cardiac arrest have been excluded
Individual has structural heart disease and spontaneous sustained ventricular tachycardia (VT)
Individual has syncope of undetermined origin with either clinically relevant, hemodynamically significant sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) induced at electrophysiological study
Individual with long-QT syndrome who is experiencing syncope or VT while receiving beta blockers
Individual hasa Left Ventricular Ejection Fraction (LVEF) less than 35% due toa prior myocardial infarction (MI) that occurred at least 40 days ago.
Individual has nonischemic dilated cardiomyopathy (NIDCM) with an LVEF less than or equal to 35%
Individual has nonsustained VT due to a prior MI, LVEF less than 40%and inducible VF or sustained VT at electrophysiological study
Individual has ischemic cardiomyopathy, has not had an MI in the past 40 daysand has an LVEF less than 30% (if checked please complete below)
Individual has left ventricular systolic dysfunction associated with marked stenosis (at least 75% narrowing) of at least 1 of the 3 coronary arteries
Individual has a documented history of myocardial infarction
Individual has confirmed hypertrophic cardiomyopathy (HCM) with two (2) or more major risk factors for sudden cardiac death (if checked please complete below)
Family history of HCM-related SCD in at least 1 first-degree relative
At least 1 episode of unexplained syncope within the previous 12 months
NonsustainedVT on ECG
Abnormal blood pressure (BP) response during upright exercise testing
Left Ventricular (LV) wall thickness greater than or equal to 30 mm
Other (Please list):
Other (Please list):
*** MUST BE COMPLETED***
Please classify the individual according to the New York Heart Association (NYHA) definitions:
CLASS I – Individual with cardiac disease but without resulting limitation of physical activity; ordinary physical activity does not cause undue fatigue, palpitation , dyspnea, or anginal pain; symptoms only occur on severe exertion
CLASS II – Individual has cardiac disease resulting in slight limitation of physical activity; they are comfortable at rest; ordinary physical activity (e.g., moderate physical exertion, such as carrying shopping bags up several flights of stairs) result in fatigue, palpitation, dyspnea, or anginal pain.
CLASS III – Individual has cardiac disease resulting in marked limitation of physical activity; they are comfortable at rest; less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.
CLASS IV – Individual has cardiac disease resulting in the inability to carry on any physical activity without discomfort; symptoms of heart failure or the anginal syndrome may be present even at rest; if any physical activity is undertaken, discomfort is increased.
PEDIATRIC INDICATIONS
Request is for implantable cardioverter-defibrillator (ICD) therapy in a pediatric individual
Request is for ICD/Biventricular pacing (CRT/ICD) device (*** If checked, you must complete and submit this document as well as the Clinical Data Submission Tool - SURG.00064 Cardiac Resyncronizing Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure ***)
Request is to treat ventricular tachyarrhythmias and to prevent sudden cardiac death (SCD)
Individual is receiving optimal medical therapy
Individual has a reasonable expectation of survival with a good functional status for more than 1 year
Individual is a survivor of cardiac arrest, has been evaluated and any reversible causes of the event have been excluded
Individual has symptomatic sustained ventricular tachycardia (VT) in association with congenital heart disease and has undergone hemodynamic and electrophysiological evaluation
Individual has congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias at electrophysiological study
Other (Please list):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
______
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Page 1 of 3
REVIEW REQUEST FOR
Implantable Cardioverter-Defibrillator (ICD)
Provider Data Collection Tool Based on Medical PolicySURG.00033
Policy Last Review Date: 11/18/2010 / Policy Effective Date: 12/01/2010 / Provider Tool Effective Date: 12/01/2010Page 1 of 3